People who earn up to 400% of the poverty level (about $48,500 for an individual and $100,400 for a family of four in 2019) are eligible for subsidies of the cost of their marketplace health plans. But many of the 5 million who aren't eligible feel crushed by rising costs.

The Trump Administration has made changes to the ACA's rules, including eliminating the tax penalty for those who don't buy coverage, and making it easier for some people to buy a short-term policy that doesn't carry all the consumer protections of an ACA policy.

Enrollment for the exchanges fell to about 11.8 million people during open enrollment for 2018. That was a 4% drop from the previous year. While state-run exchanges saw a 0.2% increase, enrollment in states with the federal-run exchanges decreased 5.3%.

The average decrease comes despite accusations from critics that the Trump administration has sabotaged the exchanges by repealing the individual mandate, cutting of cost-sharing reduction payments and slashing funding the Affordable Care Act’s Navigator program.

The recommendations by the GAO includes establishing numeric enrollment targets, ensuring information for navigator organization awards are accurate and exploring other parts of the consumer experience.

CMS administrator Seema Verma said that the need for federally funded Navigators has diminished. Funding for navigators has been drastically reduced since 2016, when the program was allocated $62.5 million.